Case Manager Advanced

JOB SUMMARY

At Houston Methodist, the Advanced Case Manager (CM) position is a registered nurse (RN) responsible for promoting the achievement of optimal clinical and resource outcomes, accountable for a designated assignment that is considered more complex and resource intensive. This position has achieved an expert level at all the objectives delineated in the Case Manager and Case Manager Certified job roles and is responsible for facilitating appropriate lengths of stay (LOS) and reimbursement for all hospital admissions in accordance with set goals and objective. The Advanced Case Manager position assures that admission and continued stay are medically necessary, communicating clinical information to payers to ensure reimbursement. The Advanced CM position analyzes variances to identify opportunities for improvement and acts as the key information and education resource for the interprofessional health care team. This position promotes and maintains compassionate, quality of care through collaboration with all service team members, patients and families and works with the leadership team for special project activities related but not limited to, throughput, readmissions, and utilization management to align with the visions and goals of the department and organization. The Advanced CM position will lead projects or perform specialized responsibilities as a regular part of their normal job responsibilities.

PRIMARY JOB RESPONSIBILITIES

Job responsibilities labeled EF capture those duties that are essential functions of the job.

PEOPLE - 25%

1. Promotes a positive work environment and leads the team to be a dynamic, team-focused work unit that actively helps one another to achieve optimal department results. Acts as a role model to team members exemplifying effective communication skills. Collaborates with all members of the patient care team by actively communicating and reporting pertinent patient care information and data in a comprehensive manner. (EF)
2. Works with physician leadership and the interprofessional healthcare team for defined patient populations to develop clinical pathways, continuum care management programs, measurement and feedback of performance indicators for cost, quality and service and patient satisfaction. (EF)
3. Serves as the primary information resource for case management staff, payors, physicians, other healthcare team members and customers. Acts as a formal preceptor/coach for new case management employees. Develops skills of team members and continually assists with improving skills, performance and outcomes. Provides feedback to management on team member performance and conduct. (EF)
4. Conducts self in a manner that is congruent with cultural diversity, equity and inclusion principles. Collaborates with leadership team on recruitment and retention strategies and key initiatives to improve employee relations, participation and engagement. Initiates improvement of department scores for employee engagement, i.e. peer-to-peer accountability. (EF)

SERVICE - 20%

1. Serves as a leader for comprehensive case management activities including assessing all patients and leading team to set discharge plan, participating in daily rounds or discussions, identifying and leading resolution of barriers to efficient patient throughput. (EF)
2. Continuously reviews the total picture of the patient for opportunities for care facilitation and needs for discharge planning. Mentors others regarding specialty populations. (EF)
3. Independently handles resolution of complex problems and issues. Serves as escalation support for novice staff. Implements and leads initiatives to improve patient and family satisfaction related to discharge question(s) on HCAHPS. (EF)

QUALITY/SAFETY - 20%

1. Identifies need for case management and/or social work intervention and implements strategies that improve care coordination metrics (LOS reduction, discharges before 11am and readmission reduction) by using clinical expertise and high-risk screening tools. (EF)
2. Actively participate in system-wide projects regarding Case Management related topics such as length of stay reduction, readmission prevention, utilization management denial mitigation and appeal resolution. Identifies opportunities for process improvement to improve the quality of case management and social work documentation, providing recommendations to meeting department and hospital targets for quality and safety. Works with the department leadership to create and/or enhance current operational and documentation of efficiencies to improve the quality of information in the medical record. (EF)
3. Performs chart audits to assess for compliance with department-specific tasks and documentation. Tracks and trends performance and reports to department leadership. (EF)

FINANCE - 25%

1. Oversees the management of specific patient populations across the continuum, focusing on high-risk, high-cost patients. Takes leadership role in collaborating with employees to secure reimbursement for hospital services. Collaborates with department leadership on cost-reduction strategies. Leads efforts to ensure appropriate capture of avoidable and excess days. Reports trends to department leadership team. (EF)
2. Functions as resource to department staff in communicating medical information required by external review entities, managed care contractors, insurers, fiscal intermediaries, state, and federal agencies. Collaborates with the appropriate resources to mitigate denials. (EF)
3. Collaborates with department leadership on efforts to reduce length of stay (LOS) including serving as the resource to staff on proactively identifying and assessing difficult discharges, timely escalation, and progressive care coordination for next level of care arrangement and transition. (EF)

GROWTH/INNOVATION - 10%

1. Expands own knowledge and serves as instructor in continuing education or formal program and expert consultation; coaches staff to grow in knowledge, abilities, skills, and attitudes. Reads and leads critique of evidence-based practice literature in case management and related disciplines. Identifies, plans, and implements education for the unit and service line in collaboration with team members and interprofessional partners. (EF)
2. Fulfills role of leadership on at least one hospital or system-based committee. Seeks opportunities to identify self-development needs and takes appropriate action. Ensures own career discussions occur with appropriate management. Completes and updates the My Development Plan on an on-going basis. (EF)

This job description is not intended to be all inclusive; the employee will also perform other reasonably related business/job duties as assigned. Houston Methodist reserves the right to revise job duties and responsibilities as the need arises.

EDUCATION REQUIREMENTS

o Bachelor’s degree or higher in nursing

o Master’s degree preferred

EXPERIENCE REQUIREMENTS

o Seven years hospital clinical nursing experience which includes five years in case management